Home‐ and community‐level predictors of social connection in nursing home residents: A scoping review

Abstract Background and Aims Social connection is associated with better physical and mental health and is an important aspect of the quality of care for nursing home residents. The primary objective of this scoping review was to answer the question: what nursing home and community characteristics have been tested as predictors of social connection in nursing home residents? The secondary objective was to describe the measures of social connection used in these studies. Methods We searched MEDLINE(R) ALL (Ovid), CINAHL (EBSCO), APA PsycINFO (Ovid), Scopus, Sociological Abstracts (ProQuest), Embase and Embase Classic (Ovid), Emcare Nursing (Ovid), and AgeLine (EBSCO) for research that quantified associations between nursing home and/or community characteristics and resident social connection. Searches were limited to English‐language articles published from database inception to search date (July 2019) and update (January 2021). Results We found 45 studies that examined small‐scale home‐like settings (17 studies), facility characteristics (14 studies), staffing characteristics (11 studies), care philosophy (nine studies), and community characteristics (five studies). Eight studies assessed multiple home or community‐level exposures. The most frequent measures of social connection were study‐specific assessments of social engagement (11 studies), the Index of Social Engagement (eight studies) and Qualidem social relations (six studies), and/or social isolation (five studies) subscales. Ten studies assessed multiple social connection outcomes. Conclusion Research has assessed small‐scale home‐like settings, facility characteristics, staffing characteristics, care philosophy, and community characteristics as predictors of social connection in nursing home residents. In these studies, there was no broad consensus on best approach(es) to the measurement of social connection. Further research is needed to build an evidence‐base on how modifiable built environment, staffing and care philosophy characteristics—and the interactions between these factors—impact residents' social connection.


| INTRODUCTION
COVID-19, and the infection control measures enacted to prevent it, have highlighted the importance of social connection to the health and well-being of nursing home residents. 1 Relationships between residents as well as those with family and staff contribute to resident well-being 2 and are a key aspect of both quality of life 3 and quality of care 4 in nursing homes.
Social connection depends on the existence, roles, and qualities of relationships as well as the sense of connection within these relationships. 5 Social connection encompasses distinct aspects, including loneliness, social support, and social engagement. 6 Multiple aspects of social connection have been highlighted for research in nursing homes. 7 Nursing home design and location have been described as important influences on social connection for residents 8 and nursing home residents have expressed the importance of designing nursing homes accordingly. 9 Although nursing home characteristics have been found to impact quality of life, 10 surprisingly little quantitative research has been published in this area. A 2013 systematic review assessing the impact of nursing home characteristics on overall resident quality of life found 11 studies with mixed results and an inadequate evidence base. 11 Subsequent reviews focused on quality of life have highlighted the influence of physical environments 12 and design 13 for residents with dementia. The impact of community characteristics on resident social connection and quality of life more broadly, is even less clear. The objective of this scoping review is to summarize published research testing nursing home-and communitylevel predictors of social connection in residents. By identifying gaps in knowledge, this review will inform future research on approaches to building and maintaining social connection among nursing home residents.

| METHODS
Our scoping review was designed to map research evidence on social connection in nursing homes. It followed a published protocol, 14 used a six-stage approach 15,16 and is reported according to the PRISMA Extension for Scoping Reviews. 17

| Step 1: Identifying the research questions
We sought to address the research question: what nursing home and community characteristics have been tested as predictors of social connection in nursing home residents? This question evolved from the needs of knowledge users after completing a scoping review examining the mental health impacts of social connection and potential strategies during COVID-19. 18 As a secondary objective, from these studies, we described the measures that were used to assess social connection in nursing home residents.

| Step 2: Searching for relevant studies
Published observational and intervention studies were eligible for this review if they met each of these criteria: • Population: reported results from adult residents of nursing homes. Studies conducted in other settings, including assisted living facilities and retirement homes, were not included.
• Intervention: delivered at the nursing home or community level or • Exposure: assessed nursing home or community characteristics with an ecological measure (i.e., properties of groups or places). 19 • Comparator: any.
• Outcome: reported any quantitative measure of social connection (including social networks, social support, social engagement, social isolation, loneliness, social capital, and social connectedness), including where assessed through quality-of-life subscales.
A comprehensive search strategy 14 was developed with an experienced information specialist. We searched multiple databases in the fields on health sciences and focused on subareas of healthcare such as nursing and allied health. We also explored the social sciences and a multidisciplinary database.

| Step 3: Selecting studies
As part of the initial review, two reviewers independently screened titles and abstracts then full articles to identify potentially relevant studies (i.e., studies that quantified social connection in nursing home residents). Any disagreements were resolved by a third reviewer. For this subanalysis, two reviewers independently reviewed these full text papers to identify the subset of studies that met the criteria listed in step 2 (above). We also scanned reference lists from relevant reviews. [11][12][13][20][21][22] 2.4 | Step 4: Charting the data Two reviewers independently extracted data from the included studies. We summarized studies according to study characteristics and reported a narrative synthesis of the results. 15,16 In keeping with scoping review methodology, 17 we did not undertake a formal quality assessment of the studies.

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Step 5: Collating, summarizing, and reporting the results We reviewed the results in an iterative manner, suggested refinements, and provided insights on the findings.

| Step 6: Consulting with stakeholders
Members of the study team include representatives from organizations that represent nursing home staff, families, and residents. These stakeholders became involved in the review after the publication of the study protocol. 14 The first reports highlighted mental health outcomes and potential strategies during COVID-19. 18,23 The second publication focused on physical health outcomes. 24   80%) did not measure social connection using resident's self-reported information. Six studies testing the association between home size and residents' social connection produced mixed results. Three studies found the smaller home size was associated with better social connection, including higher social engagement, 28,30 and less social isolation. 30 Conversely, one study found no statistically significant association between home size and relationships 31 and other studies reported larger home size was associated with higher social engagement, 32 and reduced social withdrawal. 33 Some studies analyzed a continuous variable 29,32,33 and others used different characterizations of "small", "medium" and "large" 28,30,31 ; for the latter, "large" homes were those with more than 100 residents.

| Ownership (i.e., profit status)
Five studies tested the association between ownership and residents' social connection, and none reported a statistically significant association. 28 Five studies examined the type of ward or unit within the home and produced mixed results. Two studies reported a significantly higher social connection among residents in dementia special care units, in particular higher social engagement 34 and social contact with staff. 35 A third study found that residents in dementia special care units were more likely to have social interactions, but only in the afternoon. 36 Conversely, one study reported no association between residing in a special care unit and social engagement 32 and another study found that among new nursing home residents, the bivariate association between ward type and social engagement disappeared in regression models, attributing the differences between wards to resident levels of depression and functional and cognitive impairments. 37

| Shared rooms/privacy
Two studies tested the association between measures of shared rooms and residents' social connection and neither reported a statistically significant association. The proportion of private rooms within the nursing home was not associated with relationship scores 31 and type of room (single or shared) did not predict social engagement. 34

| Environment
Two studies each assessed multiple aspects of home and building environment. One study assessed temperature, noise and lighting level in different areas of the home (living room, bedroom, and dining room) among residents with advanced dementia; only the association between high noise levels in the living room and less social interaction was statistically significant in adjusted models. 38 Another study, conducted in dementia special care units, tested ratings of exit control, walking paths, individual space, common space, outdoor freedom, residential character, autonomy support and sensory comprehension; only the association between increasing common spaces variability (i.e., uniqueness) and decreasing social withdrawal was statistically significant. 33 F I G U R E 1 PRISMA flow diagram

| Medicaid census
Two studies reported on the association between Medicaid census (i.e., proportion of residents on Medicaid) and residents' social connection. One found higher Medicaid census was associated with improvement in social engagement score 32 whereas the other did not. 39

| Other facility characteristics
Four studies reported on other aspects of the home. One study reported occupancy rate and chain affiliation were not associated with social engagement. 32 A study that tested the association between dementia friendliness of the nursing home's mission statement and social withdrawal did not report a statistically significant association. 33 T A B L E Study-specific measures: Social engagement, using indicators or counts of participation in various social activities and contacts with visitors, staff, and residents 11 24 Social interaction, using direct observation 3 7 Social support, measure of inclusion of informal caregivers in nursing and care 1 2 Loneliness, single-item questions 1 2 Note: Column percent adds to more than 100% because some studies investigated multiple aspects of social connection.
CLEMENS ET AL. Seven studies assessed dementia special care units and most did not report statistically significant results. One study found social interaction was significantly related to this type of setting 54 and one found that social interaction was weakly related to group living characteristics. 55 However, five studies produced results that were not statistically significant. 56-60

| Other household/group-living models
Six studies assessed other small-scale settings which suggested potential benefit. One cross-sectional study of residents (with or without dementia) found that residents and staff spent more time engaged in social interactions with the household model compared to traditional nursing homes. 61 Two papers that reported from the same data of residents with dementia, pre-and post-conversion from a traditional to a household model unit, found social engagement increased post-conversion. 62,63 Another study of residents with dementia in group-living home-like settings found social engagement was higher among residents of group-living homes compared to traditional nursing home settings. 64 One longitudinal study of residents with dementia found that although social connection was higher in small-scale home-like settings, the difference was not sustained over time. 65 Another longitudinal study of residents of nursing homes in Belgium and the Netherlands reported that, in the Dutch homes, residents in small-scale settings had higher mean scores on social relations but there were no differences for social isolation or social engagement (as assessed with the Revised Index of Social Engagement and number of visits). 66

| Home-level: Staffing
Eleven studies assessed staffing characteristics, with most studying attributes of nursing care staff.

| Staffing level, mix, and staff-to-resident ratios
Six studies tested the association between staffing level, skill mix or staff-to-resident ratios, and social connection. Three of these studies reported significant results, but only for certain staff categories. The first study tested each ratio of registered nurses (RN), licensed practical nurses (LPNs), and nurse aides to residents and found lower LPNs per resident and higher nurse aides per resident were associated with improvements in social engagement. 32 The second study found that higher staffing levels of personal care assistants were associated with higher social engagement. 28 The third found relationships were negatively related to RN staffing hours. 67 A fourth study found RN to certified nursing assistant ratio was not significantly related to social engagement. 29 Two studies reported no statistically significant associations; one tested the association between total staff to resident ratios and social withdrawal, 33 and another tested the relationship between hours per resident day for RN, LPN, and certified nursing assistant, as well as skill mix and turnover for each category of staff. 68

| Nurse aide job characteristics
Two studies examined specific aspects of the roles of nurse aides.
One study collected information about nurse aides' stability (turnover and retention), empowerment strategies (e.g., delegation, influence over resident care decisions), registered nurse-to-nurse aide ratio and nurse aide unionization, to study their impact on resident social engagement. They found the amount of influence nurse aides had in resident care decisions predicted residents' social engagement, and social engagement scores were lower in facilities experiencing either high turnover and low retention or low turnover and high retention relative to facilities where both turnover and retention were high. 29 Another study evaluated the impact of a primary care nursing model on social interactions, using a permanent assignment of nursing aides to residents, a "teams-of-two" approach and enhanced communication between aides and other staff. This study found social interactions were positively associated with the use of this model of care. 69

| Other aspects of staffing
Three other studies examined aspects of staffing, including the impact of specific roles (social workers and a geriatric nurse practitioner) and staff attitudes. A multi-level cross-sectional study found that living in nursing homes with greater numbers of social workers was positively associated with social support. 40 A cohort study suggested the presence of a geriatric nurse practitioner did not improve social interaction among residents. 70 A cross-sectional study assessed the association between staff attitudes towards dementia and residents' social well-being; results showed that when care staff had a more hopeful attitude towards residents with dementia, residents displayed higher social well-being, but there was no statistically significant association for the "person-centeredness" attitude subscale. 71

| Community-level
Five studies tested a range of community characteristics. Typically measures described the population in the area surrounding the home and were defined from census data. The first considered county-level unemployment rates but was not significantly related to social engagement. 29 The second reported higher levels of market competition (Herfindahl Index); lower numbers of older adults and higher average incomes in the county were all associated with improvement in social engagement. 32 Another study used measures of the proportion of the Census tract community by race and CLEMENS ET AL. | 7 of 12 ethnicity group, working class, urban category, education, age, home value, and poverty ranking; the only statistically significant finding linked location in urban communities to lower social engagement. 39 Three other studies also reported results testing the association between rural versus urban home locations and social connection; one found nursing homes in urban areas had higher levels of social engagement 28    Recovery. They are also members of the Canadian Consortium on Neurodegeneration in Aging (CCNA). All funding sources and funding relationships were not involved in the study design, collection, analysis, and interpretation of data, writing of the report or the decision to submit this review for publication.

CONFLICT OF INTEREST
The authors declare no conflict of interest.

DATA AVAILABILITY STATEMENT
All relevant data are included in the review and/or its supplementary information files.

ETHICS STATEMENT
The manuscript submitted to Health Science Reports has been done in accordance to "Wiley's Best Practice Guidelines on Publishing Ethics" and has been performed in an ethical and responsible way, with no research misconduct, which includes, but is not limited to data fabrication and falsification, plagiarism, image manipulation, unethical research, biased reporting, authorship abuse, redundant or duplicate publication, and undeclared conflicts of interest.

TRANSPARENCY STATEMENT
As lead author, Dr. Sara Clemens affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.